Traumatic Brain Injury:

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1 Traumatic Brain Injury: A Guide for Criminal Justice Professionals Many prison and jail inmates are living with traumatic brain injury (TBI)-related problems that complicate their management and treatment while incarcerated. Because most inmates will be released, these problems also pose challenges when they return to the community. The Centers for Disease Control and Prevention (CDC) recognizes TBI in prisons and jails as an important public health problem. What is Traumatic Brain Injury? A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. 1 Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from mild, with a brief change in mental status or consciousness, to severe, with an extended period of unconsciousness or amnesia after the injury. 1 A study of young adults found that those with a TBI were at risk for sustaining another, 2,3 and that a history of multiple TBIs is associated with slower recovery. 4 What are the causes of TBI? The leading causes of TBI are falls, motor vehicle-traffic crashes, struck by or against events, and assaults. 5 Blasts are the leading cause of TBI among active duty military personnel in war zones. 8 What are the long-term consequences of TBI? A person with a TBI can experience short- or long-term problems, requiring help in performing activities of daily living. 1,6 A TBI can cause a wide range of problems in thinking, sensation, learning, language, behavior, and/or emotions Persons with TBI may experience mental health problems such as severe depression, 12 anxiety, 13 difficulty controlling anger 14 and alcohol or substance abuse. 15,16 How many people have TBI? Each year, on average 1.4 million people in the United States sustain a TBI. Of this number, 50,000 die, 235,000 are hospitalized, and 1.1 million are treated and released from an emergency department. 5 At least 5.3 million Americans are living with TBI-related disabilities. 6 The number of people with TBI who are not seen in an emergency department or who receive no care is unknown. 7

2 TBI can also cause epilepsy and increase the risk for both Alzheimer s and Parkinson s diseases and other brain disorders associated with increasing age. 9 What is known about the extent of TBI and related problems within the criminal justice system? General: According to jail and prison studies, 25-87% of inmates report having experienced a head injury or TBI as compared to 8.5% in a general population reporting a history of TBI. 20 Inmates who reported head injuries are more likely to have disciplinary problems during incarceration. 21 Inmates with head injuries may have seizures 19 or mental health problems such as anxiety 22 or suicidal thoughts and/or attempts. 22,23 Studies of inmates self-reported health indicated that inmates with one or more head injuries have significantly higher levels of alcohol and/or drug use during the year preceding their current incarceration. 22 The U.S. Department of Justice has reported that 52% of female and 41% of male offenders were under the influence of drugs, alcohol, or both at the time of their arrest, 24 and that 64% of male arrestees tested positive for at least one of five illicit drugs (cocaine, opioids, marijuana, methamphetamines, or PCP). 25 Although more than half of prison inmates have a lifetime history of drug use disorders, 26 fewer than 15% receive substance abuse treatment services while in prison. 27 Women and Families: Female inmates who are convicted of a violent crime, are more likely to have sustained a pre-crime TBI and/or some other form of physical abuse. 28 Children and teenagers who have been convicted of a crime are more likely to have sustained a pre-crime TBI 29 and/or some other form of physical abuse Among male inmates, a history of TBI is strongly associated with perpetration of domestic violence and other kinds of violence during their lifetimes. 32 Corrections and Law Enforcement Officers: Corrections personnel and law enforcement officers are at risk for head injury or fatal head trauma. 33,34 Interactions with suspects prior to arrest and with inmates during their incarceration are considered high risk situations for injury or death due to head trauma. 35 How might inmates with TBI and others be affected by TBI-related problems? Within the correctional setting, TBI can contribute to situations that lead to disciplinary action. Here are some common TBI problems and strategies for management: Attention deficits may make it difficult for the inmate with TBI to focus on a required task or respond to directions given by a corrections officer. Either situation may be misinterpreted, thus leading to an impression of deliberate defiance on the part of the inmate. 17,36 Ask the inmate to repeat what you have said to confirm that he or she has heard and understood your directions Encourage the inmate to write down steps for the task Allow extra time for the task to be done Clear or reduce environmental distractions Memory deficits can make it difficult to understand or remember rules or directions, which may lead to disciplinary actions by jail or prison staff. 21 Explain rules or directions slowly, step-by-step

3 Ask the inmate to repeat the steps and encourage him or her to write down the information Provide examples and ask the inmate to provide his or her own Teach the inmate to ask questions when he or she doesn t understand Slowed verbal and physical responses may be interpreted by corrections officers as uncooperative behavior. 36,37 Give directions, or ask questions, slowly; repeat if necessary Allow the inmate additional time to respond Irritability or anger may be difficult to control which can lead to an incident with another inmate or corrections officer. Such incidents can lead to further injury for the inmate with TBI and others. 37,38 Avoid arguing with the inmate Try re-phrasing the problem, breaking it down into parts Reinforce positive behaviors Uninhibited or impulsive behavior, including unacceptable sexual behavior, may provoke other inmates or result in disciplinary action by jail or prison staff. 36,39 Tell the inmate calmly that the behavior is unacceptable Seek assistance from mental health professionals How can the problem of TBI in prisons and jails be addressed? A recent report from the Commission on Safety and Abuse in America s Prisons recommended increased health screenings, evaluations, and treatment for inmates and development of partnerships with community health providers to assure continuity of care and case management for released inmates. 40 In addition, TBI experts and some prison officials have suggested the following: Routinely screen jail and prison populations to identify a history of TBI. 41,42 Screen inmates with TBI for possible alcohol and/or substance abuse and provide treatment for these co-occurring conditions. 25,43,44 Conduct additional evaluations to identify specific TBI-related problems and determine how they should be managed. 41 Special attention should be given to impulsive behavior, including violence, 39 sexual activity, 36 and suicide risk if the inmate is depressed. 45 How should TBI-related problems be addressed after release from jails and prisons? Lack of treatment and rehabilitation for inmates with mental health and substance abuse problems while incarcerated increases the probability that they will again abuse alcohol and/or drugs when released. 25,44 Persistent substance abuse can lead to homelessness, 46 return to illegal drug activities, 47 rearrest, 48 and increased risk of death 49 after release. As a result, criminal justice professionals and TBI experts have suggested the following: Community re-entry staff should be trained to identify a history of TBI and have access to appropriate consultation with other professionals with expertise in TBI. 29,41,42 Transition services should be capable of accommodating the effects of an inmate s TBI upon their release and return to the community. 29,41,42 Released inmates with mental health and/or substance abuse problems should receive case management services and assistance with placement into community treatment programs. 40,43,49 CDC supports new research to develop better methods for identifying inmates with a history of TBI and related problems and for determining how many are living with such injury.

4 Further information is available from these websites: Traumatic Brain Injury (TBI): CDC, National Center for Injury Prevention and Control This site provides information for professionals and the general public regarding TBI. Topics include prevention, causes, outcomes, and research. Data reports on TBI in the United States and many free publications and fact sheets can be downloaded. Materials are available in English and Spanish. Health Issues in Correctional Settings: CDC, National Center for HIV, STD, and TB Prevention This site provides information for public health and criminal justice professionals about health topics with an emphasis on infectious diseases in the correctional setting. It also includes materials for the general public with links to related organizations. Intimate Partner Violence (IPV): CDC, National Center for Injury Prevention and Control This site provides information for professionals and the general public regarding IPV. The site contains an overview and fact sheet about IPV, prevention strategies, links to other IPV organizations, and a list of current CDC publications. Legal Issues of Persons with TBI within Correctional Settings: National Disability Rights Network This site provides information about the laws protecting the civil and human rights of people with disabilities including those with TBI. Inmates with disabilities or their families can receive help from the Network about inmates legal rights, access to mental health services and/or medication, and restoration of benefits upon release. Substance Abuse: Substance Abuse & Mental Health Services Administration This site provides information for professionals and the general public regarding treatment resources for persons with, or at risk for, mental health and/or substance abuse problems. It also has materials for specific populations and age groups and hotlines.

5 References: 1. Department of Health and Human Services (US). National Institutes of Health. NIH consensus statement: rehabilitation of persons with traumatic brain injury (October 26-28, 1998). Ragnarsson KT, editor. Washington (DC): Government Printing Office; Zemper ED. Two-year prospective study of relative risk of a second cerebral concussion. American Journal of Physical Medicine & Rehabilitation 2003;82(9): Guskiewicz KM, Weaver NL, Padua DA, Garrett WE Jr. Epidemiology of concussion in collegiate and high school football players. American Journal of Sports Medicine 2000;28(5): Guskiewicz KM, McCrea M, Marshall SW, Cantu RC, Randolph C, Barr W, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003,290(19): Langlois JA, Rutland-Brown W, Thomas, KG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE. Traumatic brain injury in the United States: a public health perspective. Journal of Head Trauma Rehabilitation 1999;14(6): Finkelstein E, Corso P, Miller T. The incidence and economic burden of injuries in the United States. New York: Oxford University Press; Department of Defense (US), Defense and Veterans Brain Injury Center. Fact sheet on traumatic brain injury [online] [cited 2006 May 1]. Available from URL: 9. Department of Health and Human Services (US), National Institutes of Health, National Institute of Neurological Disorders and Stroke. Traumatic brain injury: hope through research [online] [cited 2006 Feb 16]. Available from URL: disorders/tbi/detail_tbi.htm. 10. Rizzo M, Tranel D. Overview of head injury and postconcussive syndrome. In: Rizzo M, Hayes R, editors. Head injury and postconcussive syndrome. New York: Churchill Livingstone; p Ylvisaker M, Todis B, Glang A, Urbanczyk B, Franklin C., DePompei R, et al. Educating students with TBI: themes and recommendations. Journal of Head Trauma Rehabilitation 2001;16(1): Alderfer BS, Arciniegas DB, Silver JM. Treatment of depression following traumatic brain injury. Journal of Head Trauma Rehabilitation 2005;20: Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, Gordon WA. Psychiatric challenges in the first 6 years after traumatic brain injury: cross-sequential analyses of Axis I disorders. Archives of Physical Medicine & Rehabilitation 2004;85:S Silver JM, Yudofsky SC, Anderson KE. Aggressive disorders. Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. 2nd ed. Washington (DC): American Psychiatric Publishing, Inc.; p Li L, Ford JA, Moore D. An exploratory study of violence, substance abuse, disability, and gender. Social Behavior & Personality 2000;28: Corrigan JD. Substance abuse as a mediating factor in outcome from traumatic brain injury. Archives of Physical Medicine and Rehabilitation 995;76(4): Schofield PW, Butler TG, Hollis SJ, Smith NE, Lee SJ, Kelso WM. Traumatic brain injury among Australian prisoners: rates, recurrence and sequelae. Brain Injury 2006;20: Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: prevalence, neuropsychological functioning and psychiatric disorders. Brain Injury 2003;17: Morrell RF, Merbitz CT, Jain S, Jain S. Traumatic brain injury in prisoners. Journal of Offender Rehabilitation 1998;27: Silver JM, Kramer R, Greenwald S, Weissman M. The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study. Brain Injury 2001;15: Merbitz C, Jain S, Good GL, Jain A. Reported head injury and disciplinary rule infractions in prison. Journal of Offender Rehabilitation 1995;22(3-4): Walker R, Hiller M, Staton M, Leukefeld CG. Head injury among drug abusers: an indicator of cooccurring problems. Journal of Psychoactive Drugs 2003;35(3): Blaauw E, Arensman E, Kraaij V, Winkel FW, Bout R. Traumatic life events and suicide risk among jail inmates: the influence of types of events, time period and significant others. Journal of Traumatic Stress 2002;15:9-16.

6 24. Department of Justice (US), Office of Justice Programs, Bureau of Justice Statistics. Women offenders [online] [cited 2006 May 15]. Available from URL: 25. Department of Health and Human Services (US), Substance Abuse and Mental Health Services Administration. Put prevention into practice. Rockville (MD): Department of Health and Human Services; Treatment Improvement Protocol (TIP) Series 44, DHHS Publication No. (SMA) [cited 2006 August 3]. Available from URL: bv.fcgi?rid=hstat5.chapter Peters RH, Greenbaum PE, Edens JF, Carter CR, Ortiz MM. Prevalence of DSM-IV substance abuse and dependence disorders among prison inmates. American Journal of Drug & Alcohol Abuse 1998;24(4): Department of Justice (US), Office of Justice Programs, Bureau of Justice Statistics. Substance abuse and treatment, state and federal prisoners [online] 1999 [cited 2006 Sep 19]. Available from URL: 28. Brewer-Smyth K, Burgess AW, Shults J. Physical and sexual abuse, salivary cortical, and neurologic correlates of violent criminal behavior in female prison inmates. Biological Psychiatry 2004;55(1): Leon-Carrion J, Ramos FJ. Blows to the head during development can predispose to violent criminal behaviour: rehabilitation of consequences of head injury is a measure for crime prevention. Brain Injury 2003;17(3): Felde AB, Westermeyer J, Thuras P. Co-morbid traumatic brain injury and substance use disorder: childhood predictors and adult correlates. Brain Injury 2006;20: Yeager CA, Lewis DO. Mental illness, neuropsychologic deficits, child abuse, and violence. Child & Adolescent Psychiatric Clinics of North America 2000;9: Cohen RA, Rosenbaum A, Kane RL, Warnken WJ, Sheldon B. Neuropsychological correlates of domestic violence. Violence and Victims 1999;14(4): Department of Labor (US), Bureau of Labor Statistics. Census of fatal occupational injuries, [online] 2006 [cited 2006, February 16]. Available from URL: 34. Safran DA, Tartaglini AJ. Workplace violence in an urban jail setting. In: VandenBos GR, Bulatao EQ, editors. Violence on the job: identifying risks and developing solutions. Washington (DC): American Psychological Association; p Koehler SA, Weiss H, Songer TJ, Rozin L, Shakir A, Ladham S, et al. Deaths among criminal suspects, law enforcement officers, civilians, and prison inmates: a coroner-based study. American Journal of Forensic Medicine & Pathology 2003;24: Kaufman CW. Handbook for correction officers and other institutional staff to identify and manage inmates with traumatic brain injuries [dissertation]. Miami, (FL): Carlos Albizu University; Available from: University Microfilms, Ann Arbor, MI. (UMI No. AAT ). 37. Maryland Police and Correctional Training Commissions. Police interaction with individuals with brain injury: student workbook [online] 2001 [cited 2006 Feb 21]. Available from URL: tbics/download/mdpolice.pdf. 38. Department of Justice (US),Office of Justice Programs, Bureau of Justice Statistics. Medical problems of inmates, 1997 [online] 2001 [cited 2006 May 15]. Available from URL: abstract/mpi97.htm. 39. Young MH, Justice JV, Erdberg P. Assault in prison and assault in prison psychiatric treatment. Journal of Forensic Science 2004;49(1): Commission on Safety and Abuse in America s Prisons. Gibbons JJ, Katzenbach NB, co-chairs. Confronting confinement [online] 2006 [cited 2006 Jun 8]. Available from URL: 41. Sarapata M, Herrmann D, Johnson T, Aycock R. The role of head injury in cognitive functioning, emotional adjustment and criminal behaviour. Brain Injury 1998;12: Fowles GP. Neuropsychologically impaired offenders: considerations for assessment and treatment. Psychiatric Annals 1988;18: Department of Health and Human Services (US), National Institutes of Health, National Institute on Drug Abuse. Principles of drug abuse treatment for criminal justice populations. Rockville (MD): National Institutes of Health; Department of Health and Human Services (US), Substance Abuse and Mental Health Services Administration. Substance use disorder treatment for people with physical and cognitive disabilities. Rockville (MD): Department of Health and Human Services; Treatment Improvement Protocol (TIP) Series 29, DHHS Publication No. (SMA) [cited 2006 Aug 3]. Available from URL: bv.fcgi?rid=hstat5.chapter

7 45. Cauffman E. A statewide screening of mental health symptoms among juvenile offenders in detention. Journal of the American Academy of Child & Adolescent Psychiatry 2004;43: Kushel MB, Hahn JA, Evans JL, Bangsberg DR, Moss AR. Revolving doors: imprisonment among the homeless and marginally housed population. American Journal of Public Health 2005;95: Burdon WM, Messina NP, Prendergast ML. The California treatment expansion initiative: aftercare participation, recidivism, and predictors of outcomes. Prison Journal 2004;84: Coid J. Correctional populations: criminal careers and recidivism. Oldham JM, Skodol AE, Bender DS, editors. Textbook of personality disorders. Washington (DC): American Psychiatric Publishing; p Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadel A, Elmore JG, et al. Release from prison a high risk of death for former inmates. New England Journal of Medicine 2007;356(2): Safer Healthier People TM

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